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Student’s Name: Juan Dela Cruz

CHAPTER 2 Section & Group: BSN4A – Group 1

REVIEW OF RELATED LITERATURE AND STUDIES

This chapter presents a survey of the literature and the studies related to the

research problem that will be investigated. It is divided into two sections: the first

will be discussing the pertinent local and foreign literature on promoting critical

thinking and the second section will deal with the studies both foreign and local.

Critical Thinking

The intellectual roots of critical thinking date back to Socrates, who

developed a method of probing questions that forced people to justify their

confident claims to knowledge. Socrates established that one cannot depend upon

those ‘in authority’ to have sound knowledge and insight. He demonstrated that

persons may have power and high position and yet be confused and irrational. He

established the importance of asking probing questions before one accepts ideas as

being worthy of belief. His method of questioning is now known as "Socratic

questioning" and is the best known critical thinking teaching strategy. Socrates set

the agenda for the tradition of critical thinking; namely, to reflectively question

common beliefs and explanations, carefully distinguishing those beliefs that are

reasonable and logical from those which, however appealing, lack adequate

evidence or rational foundation to warrant our belief. Socrates was followed by the

critical thinking of Plato (who recorded Socrates' thoughts), Aristotle, and the

Greek skeptics, all of whom emphasized that things are often very different from
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what they appear to be and that only the trained mind is prepared to see through to

their essence.

In nursing education and any other field, it involves questioning,

researching, forming opinions, verifying ideas and thoughts and then reaching a

sound conclusion. This teaching practice enhances students’ critical thinking.

Critical thinking in nursing involves decision-making and problem solving in

clinical situations that are unlike ordinary human experiences (Mazhar, 2003).

“Critical Thinking is the intentional application of rational, higher order thinking

skills, such as analysis, synthesis, problem recognition and problem solving,

inference, and evaluation”(Angelo, 2005). Combining critical thinking and analysis

to the area of problem solving will not only enhance process achievement,

but increase relevance to prepare students for an increasingly interdependent and

connected world. Analysis involves the examination of knowledge that underpins

practice. Student nurses are expected to develop critical analysis skills in clinical

practice where learners may be involved in solving complex problems or thinking

about the rationale for one’s practice. Critical analysis skills can lead to developing

critical thinking in practice (Adams, 2003). Critical action requires nurses to assess

their skills and identify potential gaps in need of professional development. Critical

reflexivity is personal analysis that involves challenging personal beliefs and

assumptions to improve professional and personal practice. Incorporating these

aspects into nursing can benefit nursing practice (Timmins, 2006).

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American Philosophical Association acknowledged Critical thinking as

important because it forms the basis of a feedback system that allows individuals to

confirm, validate, or correct decisions (Marrapodi, 2003). Incorporating critical

thinking skills during the clinical decision making process will provide

clarification, a range of potential solutions appropriate to the circumstances or

setting and reasoning to support the clinical decision made. Lipman and Deatrick

affirm that requisite to clinical decision-making is the use of critical thinking. The

“thinking” part of critical thinking can include some intuitive activity too, but it

greatly involves the intellectual or mental abilities at perceiving and processing

information, knowledge or rationale for it all (De Young, 2003). Critical thinkers

strive to be clear, accurate, precise, logical, complete, significant and fair when

they listen, speak, read and write. Critical thinkers think deeply and broadly. Their

thinking is adequate for their intended purpose (Norris, 1988). Indeed, critical

thinking is a reasoned, purposive, and reflective approach to solving problems or

addressing questions with incomplete evidence and information and for which an

incontrovertible solution is unlikely (Rudd & Baker, 2000). Critical thinking is an

investigation in order to explore a situation, question, problem or phenomenon

(Kurfiss, 2005). From this inquiry, the person is able to arrive at a reasoned

conclusion that can be justified. In critical thinking, all assumptions are open to

questioning, divergent views are aggressively sought and the inquiry is not biased

in favor of a particular outcome. An advance factor influencing the addition of

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critical thinking and reflection as an essential part of the nursing curriculum is that

competent nursing practice requires much more than content knowledge in clinical

practice (Cody, 2002). The aims of nursing practice can be identified in the

definitions of nursing to promote health, to prevent illness, to restore health, and to

facilitate coping with disability or death. To meet these aims, the nurses use

knowledge, skills, and critical thinking to give care in a variety of traditional and

expanding nursing roles. Critical thinking is essential to skilled nursing and is

therefore essential to nursing education.

The use of critical thinking is vital in examining simple and complex

situations in nurses’ day-to-day responsibilities. It is an essential means of

establishing whether the information or assessment obtained has been accurately

captured in order to articulate specifically and distinctly what the information

conveys. Critical thinking is a process for reasoning which anyone has the capacity

to master, proposing that “such a reasoning process will provide nurses with a

capacity to defend their actions” (Ulsenheimer, 1997). Alfaro-LeFevre (2000)

emphasizes that it is imperative that nurses become critical thinkers in order to

practice sound clinical judgment. He defines clinical judgment as “critical thinking

in a clinical area”. Nurses must use critical thinking skills to rigorously investigate

and reflect on all aspects of a clinical observation or problem in order to decide on

an appropriate course of action. Critical thinking belongs in nursing because

nursing is concerned with purposeful goal-directed thinking, with the primary aim
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of making judgments grounded on factual evidence rather than assumption. Nurses

are responsible on a daily basis for the quality of care provided to their patients. As

such, nurses utilize critical thinking abilities to guide quality improvement

initiatives effectively to improve patient care. Case provides examples of these

quality initiatives, such as identifying clinical indicators to monitor for the purpose

of detecting and reframing problems, and implementing and evaluating actions.

Another definition agreed cy the National League for Nursing USA is that critical

thinking in nursing practice is a discipline-specific, reflective reasoning process

that guides a nurse in generating, implementing, and evaluating approaches for

dealing with client care and professional concerns (Williams, 2006).

Watson and Glaser view critical thinking as being more than a specific set

of cognitive skills – critical thinking is also a composite of skills, knowledge and

attitudes (De Young, 2003). The authors explained that critical thinking comprises

an understanding of the nature of making inferences and generalizations and the

skills of being able to consider carefully the logic and accuracy of evidence. These

authors also express the notion that having the ability to think critically is a key

element to being fully functional in our modern complex society. For them, critical

thinking is a fundamental requirement to being able to actively participate in one’s

social and political circles. It is vital for nurses to master the skills of thinking and

reasoning in order to constructively critique the value and application of new

knowledge. One cannot always put feelings into words, data and circumstances of
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all sorts. One is successful at thinking when he or she can actually express the

various components of the issue at hand, including the recognition of the problem,

the various relevant data and information, a solution or resolution, and an

explanation to be able to put critical thoughts into words and actions. Thinking is

hard, which is why one does not see a lot of people doing it (Grafton, 2002).

Indeed, critical thinking is not easy, and the development of such skills takes effort.

But there are many strategies nurse educators can use to enhance and promote the

critical thinking of students and nurses in practice.

The American Nursing Association [(ANA), 2004] Standards has set forth the

framework necessary for critical thinking in the application of the “nursing

process". The nursing process is the tool by which all nurses can equally become

proficient at critical thinking. The nursing process contains the following criteria: 1.

Assessment, 2. Diagnosis, 3. Planning, 4. Implementation, 5. Evaluation. It is in the

application of each of these processes that the nurse may become proficient at

critical thinking. The process is driven by the client, the client’s family, and other

health team members who are also collaborating in ensuring essential client care.

Indeed, critical thinking must be present in a nurse every actions .

Nursing Educators

Preparing students to think critically is a goal of many higher education

professionals. Critical thinking has become an increasingly prominent component

of clinical nursing practice and nursing education because it is essential to make

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professional judgments that have the potential to affect patients' present and future

quality of life. Although, nursing professional judgment develops with

accumulation of knowledge and the application of logical as well as scientific

methods (De Young, 2003). Many academic departments are trying to persuade

their professors and instructors to include the strategy of teaching critical thinking

skills, identify areas in one’s course that could emphasize and teach critical

thinking, and develop problems that could be used in examination to test and

evaluate the critical thinking skills of the students. Critical thinking has an issue of

who is to teach what, when, how, to whom, and with what effect. The new twist is

critical thinking. The faculty (who), are to teach critical thinking (what) throughout

the curriculum (when), somehow (how) to all health care professional students (to

whom) so that the new practitioners will be able to function effectively and

creatively (with what effect) in the changing field of health care. Somehow or the

other, in a manner and by a method not stated, known, or clearly understood, the

faculty are to do this (Duldt, 2000). The teacher facilitates a conference or

discussion in the classroom. (Underwood & Wald, 1995) Therefore, a nurse

educator is called a facilitator. This involves creating and managing meaningful

learning experiences and stimulating students’ thinking through real world

problems (Gokhale, 2001). When this is completed by the teachers, they will be

able to bestow the needs of the students, specifically, the mental flexibility and

critical thinking skills to survive in such a rapidly changing world with a future that
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is by definition uncertain. The class consists of the students asking questions to

each other and discussing these questions. Questioning is a characteristic of critical

thinking. It is important to teach students how to ask good questions, to think

critically, in order to continue the advancement of the very fields of teachings. But

then, there is no such thing as a bad question. When a person who goes through this

process submits, he will submit with full awareness, willingness and conviction.

Every field stays alive only to the extent that fresh questions are generated and

taken seriously (De Young, 2003).

The instructors should emphasize the process used to attain knowledge

more than the knowledge itself. It is the process of learning itself that is most

applicable, and relevant to students (Atlas, 2006). Teaching critical thinking must

be a subject of intense interest among nursing educators. Nursing educators play a

vital role in improving the quality of education to assure that graduates are highly

competent and prepared to lead effectively at every level of nursing practice and

administration. Most importantly, nursing educators develop analytical and critical

thinking skills that are essential in the nurse’s ability to identify potential and

current problems or risks that have an impact upon the patient’s safety (Gatchalian,

2008). Educators’ investment in promoting critical thinking skills would certainly

seem to be worth the effort.

Within the context of Philippine society, nursing education subscribes to the

belief that national identity, cultural consciousness, moral integrity and spirituality
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are a vital component in the development of a nurse. A broad liberal education and

a multi-disciplinary approach seek to enhance this belief. Nursing education,

therefore, aims to prepare a critical thinking nurse generalist who, upon completion

of the program, demonstrates professional competencies and shall continue to

assume responsibility for personal and professional development, contributing to

the enrichment of nursing through research.

Instructors, faculty and teachers must view teaching as a process of

developing and enhancing students’ ability to learn. They shall not remain passive,

but rather, help direct and mold discussions by posing strategic questions and

helping students build each other’s ideas. According to the Mission Statement of

Nursing Education in the Philippines Society (2001), it states that it is committed

to:

1. Provide quality education that will harness the maximum potential of

the learner.

2. Develop a person who is caring, responsible, nationalist, and creative

and a critical thinking generalist who upon completion of the program

demonstrates professional competencies.

3. Develop a person who assumes responsibilities for personal and

professional growth, Inculcate ethical-legal and spiritual values.

4. Develop a graduate who is responsive to national needs and aware of

global concerns.
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Hence, the pursuit of advancement in education continues. Promoting

critical thinking is very important in striving to maintain a high level of

competency. It must be inculcated in learning and is a continuous process. It is a

skill that cannot be accomplished in one course or one learning experience, or

through the efforts of a single teacher. Indeed, efforts designed to help learners

grow in their critical thinking abilities must be integrated throughout an entire

program and learning experience, and the focus must be on continual learner

growth over time, not on perfection at a single point in time.

Student Nurses

Nurses are responsible for providing safe and effective care. Nurses collect

and assess patient information to help formulate the best plan of care for patients

daily. Fowler (De Young, 2003) states "practicing nurses and nurse educators

concur that the increasing complexity of modern health-care demands critical

thinking." As stated by Alfaro-LeFevre "critical thinking belongs in nursing

because nursing is concerned with purposeful goal-directed thinking, with the

primary aim of making judgments grounded on factual evidence rather than

speculate."

The students should be able to achieve understanding such that they learn to

evaluate view points and make decisions supported by evidences. Another thing is

that they will learn to take charge of their own thinking such as they learn to take

charge of their own lives. In today’s information age, critical thinking is necessary
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to help them carefully assess information and not just passively accept them. The

Filipino student is taught to be dependent on the teacher as one attempts to record

verbatim what the teacher says and to give this back during examinations in its

original form and with little processing. Teachers reward well-behaved and

obedient students and are uncomfortable with those who ask questions and express

a different viewpoint. To McPeck (1989), critical thinking involves both a

propensity and skill – “one must develop the disposition to use those skills”; hence,

teaching someone to be a critical thinker entails both the cognitive and the affective

domains of reasoning.

Critical thinking needs to have an on-going and interactive understanding of

both the context of care and patients’ wellness and illness (Ironside & Valiga,

2006). These factors and others have led to the development of learning

opportunities and settings that nurture students’ growth as thinkers. Students learn

best by doing or preparing their own questions based on their observations rather

than participating in a “predetermined exercise with a forgone conclusion”

(Schamel & Ayres, 2002). Evidence shows that questioning and other practices

such as being open and listening are central to preparing students for practice in

that they become comfortable with thinking from multiple perspectives of doubt

and uncertainty of evolving health care situations. Frequent questioning of the

teachers to the students enhances students’ analytical thinking and follows the class

discussion. Being a good listener in whatever the students’ response to the question
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will be then an assessment for the teacher to evaluate students’ level of critical

thinking. It is difficult for the learners to develop critical thinking when the

educator is doing all the thinking, therefore, the educator should need to know that

he should be teaching for the learners to think.

Students need this mental flexibility and critical thinking skills to survive in

a rapidly changing world with a future that is by definition uncertain. Nurses need

to be prepared for life-long learning. The future nursing profession is going to

recognize a graduate who can think critically and identify difficult clinical

phenomena. In order to solve unique and complex problems, nurses need to be

organized and utilize information innovatively.

Cognitive Skills

Cognitive skills come into play when individuals are confronted by a

problem with no immediate and obvious answer. Interpretation, analysis and

evaluation of data are performed, and inference and explanation are drawn. This

skill allows individual to make informed decisions and self-regulate in their

professional and personal lives. Self-regulation is a process of monitoring one’s

own interpretation, analysis and evaluation of information. Critical thinking

encompasses many skills, including interpretation, analysis, inference, explanation,

evaluation, and self-regulation.

The development of reasoning ability in individual has been shown to

correlate with Piaget’s cognitive theory of development. A cognitive stage

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presented by Jean Piaget suggested that children go through four separate stages in

a fixed order that is universal in all children. These stages differ in the quantity of

information acquired and the quality of knowledge and understanding at a certain

stage. Piaget suggested that movement from one stage to the next occurred when

the child reached an appropriate level of maturation and was exposed to relevant

types of experiences. Without experience, children were assumed incapable of

reaching their highest cognitive ability. Piaget’s four stages are known as the

sensorimotor, preoperational, concrete operational, and formal operational stages.

In this research study, the stage of the respondents would be in the young

adolescent to adulthood. The formal operational stage is where the respondents are

in now. This stage begins in most people at age twelve and continues into

adulthood. This stage produces a new kind of thinking that is abstract, formal, and

logical. Thinking is no longer tied to events that can be observed. A child at this

stage can think hypothetically and use logic to solve problems. Those persons who

are in this stage will be able to think logically (same as thinking critically), and this

means college students do exactly think this way. But it is thought that not all

individuals reach this level of thinking. Most studies show only forty to sixty

percent of college students and adults fully achieve it.

Age

Age was entered as a variable that may have significant influence on the

critical thinking skill level of students. A study was made by Alpan-Altug and it
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stated an interesting result that age contributes positively and significantly to the

development of critical thinking (Rudd & Baker, 2000). In the study made by

Torres and Cano (1995), 92 agriculture seniors were studied while testing for the

relationship of learning style to critical thinking. It resulted that age was

significantly related to critical thinking, and so as the gender. There is a research on

critical thinking that indicates that students' behavioral dispositions do not change

in the short term (Facione, Giancarlo & Facione, 2000), but cognitive skills can be

developed over a relatively short period of time (cited in Gokhale, 2001). In their

longitudinal study of behavioral disposition toward critical thinking, Giancarlo and

Facione (2000) discovered that undergraduate critical thinking disposition changed

significantly after two years. Specifically, significant changes in student tendency

to seek truth and confidence in thinking critically occurred during the junior and

senior years. Therefore, students in the junior years, which are the scope of the

study, might have developed their critical thinking skills.

Additionally, significant relationships were found among critical thinking,

decision-making, and the demographic variables of age, GPA, and years in nursing.

It was found that as age increased, critical thinking and clinical decision-making

also increased. According to the study, this relationship may be related to the fact

that students and graduates with no to moderate experience and knowledge were in

the younger age group, while the more experienced and knowledgeable expert

nurses were in the older age group. Thus, the older, more experienced nurses scored
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higher when thinking critically and making decisions in a specific nursing context

for which they were qualified. Cheryl Martin observed differences may have been

related more to knowledge and experience than to age (Timmins, 2006).

Sex

Sex as a predictor of critical thinking skills or dispositions was a variable

that has been evaluated by nearly all of the critical thinking studies. One of the first

to consider sex in their critical thinking research was Wilson (1999). He studied the

critical thinking ability of 203 entering college freshmen using the Watson-Glaser

test and ACT College Reports. He found that sex was a significant predictor of

critical thinking skill. On the other hand, Costa, McCrae’s and Sanchez’s study (as

cited in Facione, Giancarlo & Facione et al., 2000) examined the relationship of

personality. The study looked at sex’s influence on critical thinking in addition to

personality and found that females were more open-minded and mature in their

thinking, while males were more analytical.

From Alpan-Altug they concluded that female adolescents tend to perform

better, but this conclusion is not statistically significant (Rudd & Baker, 2000). On

the contrary, based on the study done by Whitmire (2002), women and older

students were less likely to report gains in critical thinking. Another study was

made and concluded that females were more likely than males to apply critical

thinking in scenario-based situations while males were more likely to apply critical

thinking when answering general content-based questions, a finding which may

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provide evidence to suggest why there may be gender differences with respect to

overall critical thinking skills (Fulford, Ricketts, Irani,(2000) as cited in Muzhar,

2003). Evidence from the 1990s suggests that the net effects of college on critical

thinking skills may vary in magnitude by sex. Additionally, Rodriquez (as cited in

Claytor, 1997) studied the critical thinking of 60 registered nurses (RN). None of

the individual predictors such as age, degree, career path, and years of experience,

personality type, or sex was statistically significant. The role of sex has not been as

definite. Some studies have shown sex to not be related to critical thinking skills

(Claytor, 1997), while other studies have found a significant relationship between

sex and critical thinking skills (Rudd &, Baker, 2000). Songül Tümkaya et. al.

found that gender was not a significant variable related to critical thinking

disposition or to perceived problem solving skills (cited in Rudd &, Baker, 1999).

Different results were found to whether the gender contributes to the critical ability

from the studies made from other countries.

Schools (Private and Public)

A type of school last attended is a factor where one can see how a student

developed his/her critical thinking skills. An individual who had been in a private

school will most likely have a greater possibility that he had developed critical

thinking than those who had been in public school. Private schools are considered

more advantageous for a number of reasons. On average, they are half the size of

public schools. Smaller private school class sizes enable teachers to give more
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individual attention to students compared to public schools. They may also foster a

greater sense of community among students, teachers, and parents. Principals and

teachers in private schools are also allowed more control over school policy and

discipline (Gage, 2000). "Contrary to popular belief, we can find no evidence that

private schools actually increase student performance," said Jack Jennings, the

center's president and a former staffer in the Democratic-controlled House, in a

press release. "Instead, it appears that private schools simply have higher

percentages of students who would perform well in any environment based on their

previous performance and background."

The present situation, where private school students usually perform better,

has not always been like that. In the old days, it was the other way around. Public

school students were better. The reason public school were better then was the

teachers. They were more dedicated and hard working (Cloud, 2007). As there are

different types of private schools in terms of the quality of the teaching learning

process, so also there are different types of public schools. There is no doubt that

the private school administrators pay more attention to their teachers’ input into the

pupils than do the public schools.